Researchers at the American University of Beirut Medical Center in Lebanon have found that administering a lidocaine lollipop as a single-agent anesthetic to patients undergoing an upper gastrointestinal endoscopy procedure eliminated the need for sedation in the majority of patients. The research appears in the October issue of Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the American Society for Gastrointestinal Endoscopy.
Upper endoscopy allows physicians to examine the lining of the upper part of the GI tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine).
It is often done under sedation to assure patient comfort. Upper endoscopy helps physicians evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, or difficulty swallowing. It is the best test for finding the cause of bleeding from the upper GI tract and is also more accurate than X-rays for detecting inflammation, ulcers, and tumors of the esophagus, stomach, and duodenum.
“A significant portion of the complications, as well as the cost, of upper gastrointestinal endoscopy are often attributed to conscious intravenous sedation. In this study, we compared the efficacy of topical lidocaine administered in the form of a lollipop as a single-agent anesthetic with the conventional lidocaine spray, and determined whether it decreased the need for or the amount of intravenous sedation,” said study lead author Assaad Soweid, MD, FASGE, American University of Beirut Medical Center. “We found that 32 percent of the patients given the lidocaine lollipop required intravenous sedation compared with 96 percent of the patients who received the spray. The lollipop proved to be a safe and well-tolerated topical anesthetic. It is quite promising and may be particularly important for use with the elderly, patients who have comorbidities and in office-based endoscopy.”
Lollipops have been successfully used to provide anesthesia to children before painful procedures. The concept of using a lidocaine lollipop as a single-agent anesthetic in upper endoscopy is novel and has not been reported in medical literature. Medications to achieve sedation, however, may cause potential side effects such as respiratory depression, hypotension (low blood pressure) and paradoxical agitation, in which the patient becomes agitated rather than sleepy from the sedation. These side effects happen more so in elderly patients and those with comorbid illnesses.
The lollipop used in this study was developed by the anesthesia department in collaboration with the pharmacy department at AUBMC. Fifty grams of white sugar were heated until liquefied; an equal amount of golden maple syrup was slowly added. For each lollipop, 3 mL of this mixture were poured into a small cylindric container, to which 300 mg of lidocaine hydrochloride salt was added and stirred. As the the mixture cooled and solidified, a small plastic stick was plunged at one end for holding the lollipop. The ready-to-use lollipops were then labeled and stored in a refrigerator.
Patients and Methods
Fifty patients, 18 years of age and older with no allergies to lidocaine, were seen at the American University of Beirut Medical Center for elective diagnostic upper endoscopy. The single-blinded study participants were randomly assigned to receive 300 mg of lidocaine in the form of either a lollipop or as a spray. In both study groups, the decision to administer intravenous sedation was based on the blinded endoscopist’s assessment of patient discomfort (excessive gagging, retching, restlessness and combativeness) during any part of the procedure.
Immediately after the procedure, the endoscopist filled in a questionnaire rating the quality of the procedure, the tolerability of the patient, the doses of additional sedatives used, and the level of the patient’s gag reflex.
The lollipop group had less gag reflex, accommodated scope introduction more, and tolerated the procedure better. The majority of participants in the lollipop group were satisfied with their mode of anesthesia compared with the spray group. The use of the lollipop resulted in the elimination of the need for any intravenous sedation in nearly two thirds of patients and the use of lower doses of sedatives in the rest. Researchers speculate that this would probably lead to lower rates of adverse events requiring interventions and hence lower direct and indirect costs of the procedure. Moreover, patients would require less recovery time and observation after the procedure, and could go back to work without much lost productivity.
Researchers thought that the observed effectiveness of the lollipop could be explained by the continuous release of lidocaine from sucking the lollipop, in addition to swallowing the saliva mixed with the local anesthetic. It allowed for a homogenous and slow spread of the anesthetic providing ample time to exert its effect.